Multiple component interventions for preventing falls and fall-related injuries among older people: systematic review and meta-analysis

Goodwin et al. BMC Geriatrics 2014, 14:15 http://www.biomedcentral.com/1471-2318/14/15 RESEARCH ARTICLE Open Access Multiple component interventions for preventing falls and fall-related injuries among older people: systematic review and meta-analysis Victoria A Goodwin*, Rebecca A Abbott, Rebecca Whear, Alison Bethel, Obioha C Ukoumunne, Jo Thompson-Coon and Ken Stein Abstract Background: Limited attention has been paid in the literature to multiple component fall prevention interventions that comprise two or more fixed combinations of fall prevention interventions that are not individually tailored following a risk assessment. The study objective was to determine the effect of multiple component interventions on fall rates, number of fallers and fall-related injuries among older people and to establish effect sizes of particular intervention combinations. Methods: Medline, EMBASE, CINAHL, PsychInfo, Cochrane, AMED, UK Clinical Research Network Study Portfolio, Current Controlled Trials register and Australian and New Zealand Clinical Trials register were systematically searched to August 2013 for randomised controlled trials targeting those aged 60 years and older with any medical condition or in any setting that compared multiple component interventions with no intervention, placebo or usual clinical care on the outcomes reported falls, number that fall or fall-related injuries. Included studies were appraised using the Cochrane risk of bias tool. Estimates of fall rate ratio and risk ratio were pooled across studies using random effects meta-analysis. Data synthesis took place in 2013. Results: Eighteen papers reporting 17 trials were included (5034 participants). There was a reduction in the number of people that fell (pooled risk ratio = 0.85, 95% confidence interval (95% CI) 0.80 to 0.91) and the fall rate (pooled rate ratio = 0.80, 95% CI 0.72 to 0.89) in favour of multiple component interventions when compared with controls. There was a small amount of statistical heterogeneity (I2 = 20%) across studies for fall rate and no heterogeneity across studies examining number of people that fell. Conclusions: This systematic review and meta-analysis of randomised controlled trials found evidence that multiple component interventions that are not tailored to individually assessed risk factors are effective at reducing both the number of people that fall and the fall rate. This approach should be considered as a service delivery option. Keywords: Falls, Systematic review, Aged Background Falls are a common problem affecting older people, with a third of those aged 65 and over, and half of those aged over 85, falling each year [1]. The consequences of falls are disability, reduced quality of life and financial costs to individuals and society [2]. The UK National Health Service (NHS) is reported to spend around £1.7 billion each year on falls [3]. As a consequence there has been a * Correspondence: PenCLAHRC, University of Exeter Medical School, Veysey Building, Salmon Pool Lane, Exeter EX2 4SF, UK wealth of research undertaken to establish how best to prevent falls with interventions including exercise, home safety modifications and education [4]. These interventions have been categorised into one of the following three combinations: [5] a) Single interventions e.g. exercise; b) Multifactorial interventions where two or more individually tailored interventions are provided following a risk assessment e.g. one person may receive exercise and home hazard modification © 2014 Goodwin et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Goodwin et al. BMC Geriatrics 2014, 14:15 http://www.biomedcentral.com/1471-2318/14/15 whereas another may receive home hazard and medication modifications; and, c) Multiple component interventions, where participants receive a fixed combination of two or more interventions e.g. exercise and Vitamin D. Page 2 of 8 Peninsula Collaboration for Applied Research and Care (PenCLAHRC) website (http://clahrc-peninsula.nihr.ac. uk/multi-component-interventions-for-preventing-fallsand-fall-related-injuries-among-older-people–sys.php). Literature search and eligibility criteria There is increasing evidence from meta-analyses for the effectiveness of single interventions, such as exercise, at reducing the rate of falls in community-dwelling [4] and mixed populations [6]. Home modifications have also been found to be effective at reducing fall risk [7]. Whilst combining interventions that are effective on their own might therefore seem intuitive, the evidence for combined interventions (multifactorial and multiple component as described above) is less clear. Multifactorial interventions, which require an individually tailored approach, have been shown in a meta-analysis to reduce the rate of falls [4] but there remains uncertainty in relation to reducing the number of those that fall [8]. Indeed, this is supported by a recently updated Cochrane review, including more than 13,000 participants which observed no benefit in a reduction in the number that fell [4]. These two reviews and meta-analyses [4,8] reported high levels of heterogeneity (I-squared between 60% and 69%) in the meta-analyses relating to number of people that fall, although this variation was not explained by baseline fall risk and intensity of interventions. That said, multifactorial interventions are the recommended approach for falls prevention in the UK [9] whereas multiple component interventions on the other hand, which do not necessitate an individual assessment, and might therefore be an alternative approach, have not been extensively evaluated. Whilst Gillespie and colleagues included multiple component interventions as part of their review, their synthesis was narrative with each study reported separately due to the variety of combined interventions undertaken [4]. Of the included studies that were effective, all but one included exercise but the omission of any summary data across the studies as a whole leaves an unclear picture as to the effectiveness of multiple component fall prevention programmes. The aim of this review was to establish the effectiveness of multiple component interventions, as defined by Lamb et al. [5] targeting older people, on (a) number of people that fell, (b) fall rates, and (c) number that sustained a fall-related injury, including an exploration of between-trial variability. Methods The review was conducted following the general principles of the NHS Centre for Reviews and Dissemination [10]. A pre-defi (...truncated)